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PACES 4 (CVS).Pdf PACES- CVS Adel Hasanin Ahmed CVS STEPS OF EXAMINATION (1) APPROACH THE PATIENT Read the instructions carefully for clues Approach the right hand side of the patient, shake hands, introduce yourself Ask permission to examine him “I am just going to feel your pulse and listen to your heart; is that alright?” Adjust the backrest so that the patient reclines at 45° to the mattress Expose the top half completely (2) GENERAL INSPECTION STEPS POSSIBLE FINDINGS 1. Scan the patient. Nutritional status: under/average built or overweight Abnormal facies: Marfanoid (AA, AR, MR), Down’s (VSD), Turner’s (coarctation, bicuspid AV, AS), Noonan’s (PS), malar flush (MS) Dysponea (tachyponea + use of accessory muscles of respiration; the scalene and the sternocleidomastoid) Earlobe creases → increased incidence of coronary artery disease (see theoretical notes) 2. Examine the eyes. Pull down the eyelid. Anaemia (pallor) in the conjunctivae at the guttering between the eyeball and the lower lid Cornea (arcus senilis) Pupil (Argyll-Robertson pupil) → consider syphilitic aortitis 3. Examine the mouth. Ask the patient to protrude his Central cyanosis in the under-surface of the tongue tongue. Teeth must be examined in all cases (see theoretical notes for types of cyanosis) (infective endocarditis) 4. Examine the hands: tell the patient “outstretch your Clubbing (congenital heart disease, infective hands like this (dorsum facing upwards)”… then endocarditis, atrial myxoma) “like this (palms facing upwards)”… demonstrate. Cyanosis (could be peripheral or central) Capillary pulsations (AR, PDA) Splinter haemorrhage, Osler’s nodes and Janeway lesions (infective endocarditis)… see theoretical notes Palmer erythema (consider CO2 retention) Arachnodactyly (see theoretical notes) Xanthomas (dyslipidaemia) Cool peripheries (poor flow - hyperdynamic circulation) 1 PACES- CVS Adel Hasanin Ahmed (3) PULSE STEPS POSSIBLE FINDINGS 1. Radial pulse: Check for rhythm and rate. In patients with AF, re-measure the rate by auscultation at cardiac apex, and calculate the pulse deficit . If you suspect complete heart block, recount the pulse while standing (in complete heart block, HR does not increase on standing) 2. Feel the opposite radial simultaneously. Check for any difference in pulse volume…see theoretical notes for causes of absent radial pulse 3. Radio-femoral delay: firmly apply the right thumb In coarctation of aorta, femoral pulses are of low just below the mid-inguinal point while feeling the volume and delayed relative to radial pulse radial with your left fingers. 4. Check for collapsing pulse: left up the arm and put If the pulse has a water-hammer character you will the palmer aspect of the four fingers of your left hand feel a flick (a sharp & tall up-stroke and an abrupt on the patient's wrist just below where you can easily down-stroke) which will run across all four fingers feel the radial pulse. Press gently with your palm, lift and at the same time you may feel a flick of the the patient's hand above his head and then place your axillary artery against your right palm right palm over the patient's axillary artery: If the pulse has a collapsing character but is not a frank water-hammer type then the flick runs across only two or three fingers 5. Glance at the antecubital fossa for catheter scars. Check for abnormal pulse volume or character Palpate the right brachial with your right thumb. 6. Glance at the carotid for Corrigan’s sign (visible Check for abnormal pulse volume or character (see carotid pulsation in AR). Palpate the right carotid theoretical notes for components of carotid pulse and pulse with the tip of your left thumb (between the abnormalities of the pulse volume and character) larynx and the mid point of the anterior border of the sternocleidomastoid) using gentle pressure backwards. (4) JVP: examine right JVP. STEPS POSSIBLE FINDINGS 1. The patient should be lying at 45 degrees and neck is Recognize the JVP and differentiate it from arterial fully supported by pillows so the sternomastoids are pulsation (see theoretical notes) fully relaxed. The head should be turned slightly to Identify the height in centimetres vertically above the the left side and a light shone obliquely across the sternal angle (normal 3-5 cm). neck to maximize the shadows of right venous pulsations 2. While observing the right JVP, palpate the left Check for abnormal waveforms (see theoretical notes carotid with your right thumb to time the JVP waves for normal JVP and abnormalities of the JVP in relation to the carotid pulse 3. If JVP is not visible, consider applying manoeuvres to check for low or very high levels (see theoretical notes) (5) LOCAL INSPECTION: . Scars: median sternotomy scar, left lateral/inframammary thoracotomy scar . Devices: pacemaker/AICD implant 2 PACES- CVS Adel Hasanin Ahmed (6) APEX BEAT STEPS POSSIBLE FINDINGS 1. Localize the apex beat first by inspection then by Apex beat is defined as the most inferior and most laying your fingers on the chest parallel to the lateral point of cardiac pulsation. intercostal spaces A normal apical impulse briefly lifts the palpating 2. If you cannot feel it, ask the patient to roll onto the fingers (just palpable) and is localized (in the 5th ICS left side). Then stand the index finger on it to medial to the left MCL)…see theoretical notes for localize the point of maximum impulse and assess abnormalities of the apex beat the extent of its thrust (7) PALPATION STEPS POSSIBLE FINDINGS 1. Mitral area: place your hand from the lower left Palpable S1 (tapping impulse of MS) sternal edge to the apex Palpable S3 (prominent early diastolic rapid-filling wave), often accompanied by a third heart sound in patients with left ventricular failure or mitral valve regurgitation Palpable S4 (marked presystolic distension of the left ventricle), often accompanied by a fourth heart sound in patients with an excessive left ventricular pressure load or myocardial ischemia/infarction Systolic thrill of MR (acute MR is associated with thrill in one-half of cases) Diastolic thrill of MS (uncommon- best felt with the patient in the left lateral position) 2. Left parasternal edge: place the flat of your right Left parasternal lift: starts in early systole and is palm (or the heel of your hand) parasternally over the synchronous with the LV apical impulse (See left parasternal edge and apply sustained and gentle theoretical notes for causes of left parasternal lift). pressure. Ask the patient to hold his breathing in Systolic thrill of VSD or HCM expiration. Diastolic thrill of AR (uncommon- best felt along the left sternal border with the patient leaning forwards and holding his breath after expiration) 3. Upper left sternal edge using the flat or ulnar border Palpable P2 in pulmonary hypertension of the hand. Check for: Thrill of PS, PDA, or ruptured congenital sinus of Valsalva aneurysm Palpable pulmonary artery pulsations in pulmonary hypertension, increased pulmonary blood flow (ASD) or poststenotic pulmonary artery dilation. 4. Upper right sternal edge using the flat or ulnar Systolic thrill of AS (may also be palpable at the border of the hand. Check for apex, the lower sternum, or in the neck- best felt with the patient leaning forwards and holding his breath after expiration). N.B. thrill of subclavian artery stenosis may be heard over the subclavicular area. 3 PACES- CVS Adel Hasanin Ahmed (8) AUSCULTATION STEPS POSSIBLE FINDINGS 1. Listen at the apex with the diaphragm (time with During auscultation at any area, identify and describe the the right carotid). If you hear systolic murmur following: (probably MR) → repeat on expiration, listen at the S1 & S2 (see theoretical notes for recognition and axilla and feel for thrill. abnormalities of S1 & S2) S1 Just precedes the 2. Listen at the apex with the bell (using light carotid pulsation, and S2 follows it): pressure). Repeat with patient in left lateral position . Normally both are low pitched, best heard with and his breath held after expiration (If unsure about the bell of the stethoscope the presence of mid-diastolic murmur → you may ask . See theoretical notes for the patient to touch her toes and then reclines 10 Extra sound that may precede S1 (see theoretical times). If you hear mid-diastolic murmur (probably notes for features and causes): MS) → time with the carotid and feel for thrill 1. S4 3. Reposition the patient and listen with the diaphragm Extra sounds that may follow S1 (see theoretical over the lower left sternal edge. If you hear systolic notes for features and causes): murmur (probably TR/VSD) time with the carotid, 1. Ejection click repeat on inspiration and feel for thrill. 2. Opening click of prosthetic AV 4. Listen with the diaphragm over the upper left 3. Non-Ejection Click of MVP sternal edge, and the upper right sternal edge. If Extra sounds that may follow S2 (see theoretical you hear systolic murmur (probably AS/PS) → time notes for features and causes): with the carotid and feel for thrill. 1. S3 5. Auscultate both carotids (for bruits and radiated 2. Opening Snap murmurs) 3. Opening Click of prosthetic MV 6. Ask the patient to sit up and lean forwards with his 4. Pericardial knock breath held after expiration. Listen over the right 2nd 5. Split S2 interspace and the left 3rd interspace. If you hear Pericardial rub (occupies both systole and diastole; diastolic murmur (probably AR) → time with the quality is noisy) carotid and feel for thrill. Murmurs: see the following theoretical notes: 7. Listen over the lung bases (for basal crackles and . Innocent murmur radiating murmurs) and check for sacral oedema . Pathological murmurs . The grades of murmurs . Systolic murmurs . Diastolic murmurs . Continuous murmurs . Differentiation between murmurs of TR and MR .
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